Hypertension: diagnosis and management

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Hypertension diagnosis and management

• T. Villela, MD
• University of California, San Francisco
• San Francisco General Hospital
• Family and Community Medicine Residency Program

2
Objectives

• Review the prevalence of hypertension and its
  importance as a cardiovascular risk factor
• Describe criteria for hypertension and steps in
  its initial management
• Review medications used for the management of
  hypertension
• Discuss treatment strategies based on case
  discussions

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Prevalence of Hypertension

• 50 million people in the U.S.
• 1 billion worldwide
• European Americans
• 15 of women gt 45 years of age
• 25 of men gt 45
• African Americans
• 35 of women gt 45
• 40 of men gt 45

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Classification of Blood Pressure for Adults(JNC
7, May 2003)
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Cardiovascular Risk

• 20 mmHg increment in SBP or
• 10 mmHg increment in DBP
• Doubles risk for CVD among 40-70 year olds across
  entire BP range (115/75 185/115)

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Morbidity and Mortality

• CHD/MI
• LVH and LV dysfunction
• Dysrrhythmias Afib
• Stroke
• Chronic kidney disease
• PVD
• Retinopathy

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Pharmacologic Therapy

• Consider
• Severity of BP
• End organ damage, including LVH
• Presence of other conditions or risk factors
  DM, CHD, smoking, LDL
• 50 of patients achieve goal BP with one drug
  another 30 need two
• The vast majority of patients with diabetes
  require two or more drugs

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Initial Evaluation

• Cardiac Risk Factors
• History smoking, family history, CHD
• Current diabetes (fasting glucose), dyslipidemia
  (fasting lipids)
• End Organ Damage
• History atrial fibrillation, LVH (ECG) stroke
• Current Nephropathy (GFR, U/A)

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Pharmacologic Therapy First Line

• Diuretics
• ACEIs and ARBs
• Beta Adrenergic Blockers
• Calcium Channel Blockers

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Pharmacologic Therapy

• Diuretics
• ACEI and ARBs
• Beta Blockers
• Calcium Channel Blockers
• Others
• Central Sympatholytics
• Direct Vasodilators
• Peripheral Adrenergic Inhibitors

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Diuretics

• Thiazides loop potassium sparing
• Decrease morbidity and mortality related to CHD
  in major trials
• ? plasma volume and cardiac output
• ? peripheral vascular resistance
• Anti-hypertensive effect at low doses
• Biochemical effects are dose related

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Diuretics

• Adverse effects
• Electrolytes potassium, magnesium, sodium,
  calcium, uric acid
• Glucose and cholesterol - transient

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Diuretics

• Useful in
• All populations
• Isolated systolic hypertension
• Heart failure
• Renal insufficiency (use a loop diuretic if GFR lt
  30-50)
• Combination with second drug

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Angiotensin Converting Enzyme Inhibitors

• Block formation of angiotensin II
• Promote vasodilation decrease aldosterone
• Increase bradykinin vasodilatory PGs

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Angiotensin Converting Enzyme Inhibitors

• Preferred in
• Known coronary heart disease
• At high risk for CHD
• Congestive heart failure
• Diabetes type I and II
• Nephropathy

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Angiotensin Converting Enzyme Inhibitors

• Adverse effects
• Cough (5-15 of patients)
• Skin rash, taste alterations (esp. Captopril)
• Hyperkalemia
• Hypotension, dizziness
• Renal dysfunction (up to 35 inc in SCr)
• Rare angioedema (most frequent in African
  Americans), neutropenia, proteinuria
• Contraindicated in pregnancy

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Angiotensin Receptor Blockers

• Losartan, valsartan, candesartan, et.al.
• No cough, rare angioedema
• Less potent antihypertensive effect--improves if
  combined with diuretic
• Contraindicated in pregnancy

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Beta Adrenergic Blockers

• Decrease HR, CO, renal blood flow
• Inhibit vasoconstriction
• Decrease peripheral resistance

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Beta Adrenergic Blockers

• Useful in
• Patients with LVH, angina, tachycardia, anxiety,
  migraine, glaucoma
• Patients with CHD provide significant protection
  against MI recurrence

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Beta Adrenergic Blockers

• Adverse effects
• CHF exacerbation acutely
• AV block
• Bronchospasm (in reversible disease)
• CNS depression, fatigue
• Depends on lipid solubility
• Propranolol, metoprolol gtgt atenolol
• Transient effects on carbohydrate metabolism
• Transient effects on lipid metabolism
• Labetolol lt ISAs lt others

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Beta Adrenergic BlockersJAMA 1998279 Lancet
2002 359 Lancet 2004364

• For long term benefits, thiazide diuretics
  superior to beta blockers in treatment of
  uncomplicated hypertension in elderly
• Atenolol no benefits and likely increases risk
  of poor outcomes (all-cause mortality, CV
  mortality, MI, stroke)

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Calcium Channel Blockers

• Peripheral vasodilators
• Non-dihydropiridines diltiazem, verapamil
• Dihydropiridines amlodipine, felodipine,
  isradipine, nicardipine, nifedipine, nisoldipine
• Short-acting dihydropiridines

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Short Acting Nifedipine (xx)

• Not FDA approved for treatment of hypertension
• Poorly absorbed from oral mucosa
• Adverse effects neurological symptoms,
  hypotension, myocardial ischemia, acute MI
• Similar concerns with other short acting CCB like
  isradipine

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Calcium Channel Blockers

• Adverse effects
• Dizziness, headache, peripheral edema
• DHPs worse edema, flushing, tachycardia, rash
• Non-DHPs CHF exacerbation, AV block,
  bradycardia, constipation

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Calcium Channel Blockers

• Useful in angina
• Most effective in African Americans as single
  drug therapy
• In patients with DM, its use assoc. with greater
  risk of MI compared with ACEI

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Alpha Adrenergic Blockers

• Prazosin, terazosin, doxazosin
• Can cause postural hypotension and syncope
• Use with caution in elderly
• Useful in men with BPH
• Caution with concurrent use of sildenafil,
  vardenafil, tadalafil

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Central Sympatholytics

• Adverse effects sedation, drowsiness, dry
  mouth, bradycardia, heart block
• Clonidine withdrawal hypertension, headache,
  palpitations, perspiration
• Methyldopa hepatitis, lupus-like syndrome,
  thrombocytopenia, hemolytic anemia

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Direct Vasodilators

• Tachycardia can aggravate angina
• Headache, dizziness, fluid retention
• Hydralazine lupus-like syndrome, hepatitis
• Minoxidil hirsutism, pericardial effusion

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Peripheral Adrenergic Inhibitors

• Guanadrel and reserpine
• Orthostatic hypotension, diarrhea, drowsiness,
  bradycardia
• Reserpine depression, sedation, nasal
  congestion
• Useful when other treatments fail

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Goals of therapy

• Decrease morbidity and mortality
• Stroke, CHD, CHF
• Maintain function/quality of life
• Minimize side effects
• Treat co-morbidities
• Maximize therapy of other CV risk factors

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Classification of Blood Pressure for Adults(JNC
7, May 2003)
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Stage 1, No Compelling Indications

• Thiazide diuretic for most patients
• Consider ACEI, ARB, BB, CCB

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Compelling Indications

• IHD ACEI, BB, L.A.CCB
• CHF ACEI, ARB, BB, spironolactone, loop
  diuretics
• DM ThD, ACEI, ARB, BB, L.A.CCB
• Renal disease ACEI, ARB, loop diuretics
• CVA ThD, ACEI

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Compelling Indications
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Stage 2, No Compelling Indications

• 2-drug combination for most patients
• Thiazide diuretic plus ACEI, ARB, BB, CCB

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Patient D.M.

• 49 year old, feels healthy, his wife wants him to
  have his cholesterol checked they immigrated
  from Honduras 13 years ago
• BP 160/85
• ECG sinus, no LVH
• SCreat 0.8 electrolytes normal LDL 100
• FBG 200
• UA no proteinuria

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Patient D.M., cont.

• Choices
• Low dose thiazide diuretic
• ACE Inhibitor
• Beta Blocker
• Others?
• Treatment of concurrent RFs
• Diabetes
• Smoking
• Diet DASH diet
• Exercise
• Others?

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Patient C.K.

• 70 year old woman, retired MUNI driver, has
  history of HTN for 20 years has been on atenolol
  and losartan for three years no history of CHD
  events. On pravastatin for dyslipidemia. BP
  160/85
• Electrolytes normal
• SCreat 1.0
• FBG 88 LDL 100
• EKG sinus, LVH, no ST/TW changes
• UA 1 protein

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Patient C.K., cont.

• Has been on atenolol for 12 years
• She developed a cough on benazepril, so was
  switched to ARB
• Calculate and use GFR rather than SCreat

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Patient C.K., cont.

• Choices
• Diuretic, diuretic, diuretic
• Taper off atenolol, maximize ACE receptor blocker
• If not at goal BP (SBP130), begin alternative
  beta blocker (metoprolol XL) or long acting
  di-hydropiridine CCB

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The end